Putting the Power of Self-Knowledge to Work

Dr. Gillespie talked with Sarah Pike about her family history during a routine exam for her baby at The Children’s Clinic in Portland, Ore. Children exposed to “toxic stress” are at risk for problems throughout their lives. Credit Kristyna Wentz-Graff/The Oregonian/OregonLive

Thirty years ago, the Nobel Prize-winning novelist Doris Lessing gave a series of lectures, later published in a book, “Prisons We Choose to Live Inside,” in which she reflected on the brutality in the world and asked how individuals and societies could evolve into something better.

It’s a sobering book, but Lessing is hopeful — and her main source of hope stems from the capacity of human beings to study themselves and learn from their own behavior. “I think when people look back at our time, they will be amazed at one thing more than any other,” she writes. “It is this — that we do know more about ourselves now than other people did in the past, but that very little of this knowledge has been put into effect.”

Last week, and the week before, I reported on efforts over the past two decades to put more of this kind of knowledge into effect. Specifically, I examined how community-based networks were sharing research with professionals and residents in numerous communities, about how the effects of childhood trauma — so-called adverse childhood experiences, or ACEs — substantially increase risks for a range of negative outcomes, including dropping out of school, abusing drugs, becoming depressed, committing suicide, and being a victim of, or a perpetrator, of violence or abuse. (For information about ACEs, including the landmark ACE study and “ACE scores,” see these infographics and resources.)

This research didn’t exist when Lessing gave her lectures in 1985, and it’s still largely unknown to Americans, much like cholesterol was before the 1980s. But social scientists now see it as a major factor behind an array of social ills and chronic diseases. And today, a growing network of health care professionals, educators, government officials, social service workers and community leaders are working to get knowledge about ACEs into public consciousness.

“There are about 100 to 200 state, county and city ACEs initiatives around the country,” said Jane Stevens, editor of ACEs Too High, a news site that covers this issue. Most of these initiatives have sprouted up within the past eight years. Stevens has established a social network, ACEs Connection, to link them, map their spread, and share experiences. She reports that, to date, 32 states, and Washington, D.C., have conducted studies to evaluate levels of childhood adversity among their residents. The findings across states are remarkably consistent. ACEs are common. Close to one in four people has three or more of these experiences, and they are far more prevalent among people under age 55.

Perhaps the most important insight emerging from this work is simply the recognition that sharing this knowledge can be helpful in and of itself. As Chekhov put it: “Man will become better when you show him what he is like.”

Principal Godwin Higa of Cherokee Point Elementary School, the first trauma-informed school in San Diego, Ca., helps a student sort out his troubles. Credit Jane Stevens

“A lot of people who have high ACE scores don’t realize that things that they, or others, thought were normal had hurt them,” said Stevens, who has experienced seven different forms of ACEs herself. “They weren’t born bad. But children tend to think magically. If they suffered emotional or physical abuse, they think they must have deserved it or caused it. And later, in the absence of healthy options, the way they cope with the pain, anxiety or shame is often by self-medicating. Nicotine is a great anti-anxiety medication, and the first prescription antidepressants were methamphetamines.”

“In my experience people who have experienced a lot of ACEs don’t put it all together for themselves,” adds Robert Anda, a co-investigator of the original ACE Study. But once they do, he said, “they have an opportunity to understand their own lives better and they can change.”

That has been the experience of a group called Minnesota Communities Caring for Children, which works to prevent child abuse. Since 2013, they have trained 130 presenters who have disseminated the ACE research in more than half of the counties across the state. “One thing we’ve found that’s surprising is how much impact comes just from awareness,” said Becky Dale, the organization’s chief operating officer.

Almost immediately, she said, trainers bring the insights into their own institutions, whether it’s public schools, university systems, or health care settings. They start thinking about the implications. And many participants want to talk about it with their parents and siblings.

Susan Beaulieu, who is piloting this work in tribal communities across Minnesota, says the spread of this knowledge has been transformative for many individuals. “There’s so much historic trauma in tribal communities,” she said. “Traditionally, children were seen as sacred beings and abuse was nonexistent.” But generations of displacement and discrimination, including the practice of removing tribal children from their families and placing them in boarding schools, where neglect and abuse were common, has contributed to persistently high rates of alcoholism, drug use and incarceration.

When Beaulieu presents the ACEs research, it elicits a powerful response. “The resounding message I get from people is, ‘Everybody should know about this,’ ” she said. “One mother told me, ‘I wish I would have known this before I became a parent.’ Another said, ‘I wish my younger self could have known about it so I could have understood why I was the way I was.’ ”

A group of moms with their babies celebrated one year at the “group well-child care” in Dorchester, Mass., this medical model provides additional social support for moms facing serious life adversities. Credit Morgan Brockington

“Usually, we’re so focused on the symptom level — addiction, abuse, disease,” she added. “The ACEs knowledge is helping us step back and see what’s driving these things and what we can do about it. And it shifts the conversation from, ‘Are you a good or bad person?’ to ‘What happened to us when we were growing up and how has this translated to our own parenting?’ ”

Beaulieu has experienced this firsthand; now she and her mother have greater understanding of their upbringings, she said, and this has changed the way Beaulieu interacts with her own children, and led to greater intimacy with her mother.

The original ACE Study was published in 1998. It’s taken almost 20 years for the understandings to begin to be integrated in larger systems. “There should be a national education program for the general public and for people who provide services in all the systems — mental health, substance abuse, education — like there was for heart disease, diabetes and cholesterol,” said Robert Anda. “The public should have a broad understanding of this so they will demand changes in policy and practice.”

One bright light is Oregon, where two of the state’s Coordinated Care Organizations, Jackson Care Connect and AllCare, have been integrating the ACEs framework into their services. Elsewhere, groups or networks have formed to spread the knowledge into other systems and communities: They include the National Council on Behavioral Health’s Trauma-Informed Care Learning Community, the Sanctuary Institute and the ACE Interface, a training firm co-founded by Anda and Laura Porter, former director of the Family Policy Council, which provided guidance to the groups in Minnesota and Oregon.

Another network, Mobilizing Action for Resilient Communities, a learning collaborative coordinated by the Health Federation of Philadelphia, is working with 14 community networks across the country that are trying to prevent and mitigate ACEs.

One of the toughest systems to crack is corrections. But in Washington State, the deputy secretary of the Department of Corrections, Jody Becker-Green, served as the chair of the Family Policy Council for four years, so she is steeped in the ACEs science.

“We know that people are coming into our system with trauma, but oftentimes that trauma is overlooked because of their criminal offense,” she said. It doesn’t make sense to ignore it, she added. “Approximately 96 percent of the individuals who are incarcerated in one of our prisons is going home, back to a community or a family.”

At present, the department’s recidivism rate — which it defines as committing a felony and returning to prison within three years — is 32 percent. Becker-Green’s goal is to lower it to 25 percent by 2020.

In June, the department began working toward this goal by hosting the first of several planned “Hope Cafes” using the “World Café Method,” inviting 200 men incarcerated at the Stafford Creek Corrections Center in Aberdeen, Wash., for a two-and-a-half-hour conversation about recidivism.

“We had round tables, paper and markers, flowers, food, coffee, Miles Davis playing in the background,” recalled Becker-Green. “It was a very different look and feel for inside a prison. I’m sure I pushed the boundaries on many security issues.”

Everyone received a program, which included data and graphs about recidivism, a description of the World Café format, and three questions to help the department better understand recidivism and take steps to reduce it.

Offenders had many ideas. They talked about housing, mental health, addiction, the legal system, difficulties accessing programs. They said they wanted to understand the “trauma they had experienced in their life and how it impacted them in terms of the decisions that landed them in prison,” said Becker-Green, who plans to share the research from all the Hope cafes with the participants and discuss its implications with them.

Stevens of ACEs Too High made it clear that making changes like these — not by ratcheting up punishment, but by focusing on root causes — was not a matter of politics or idealism but of science: “It’s like before we knew about tectonic plates, we couldn’t prepare for earthquakes. Now we don’t build across fault lines, the building codes have changed, the emergency responses have changed. It’s like that. We’re shifting to another level of knowledge about our own human development.”